Is apixaban (Eliquis) contraindicated in thrombocytopenia?

Apixaban in Thrombocytopenia: Contraindications and Management

Apixaban is not absolutely contraindicated in thrombocytopenia, but caution is warranted with platelet counts below 125 × 10^9/L due to increased bleeding risk. 1

Understanding Thrombocytopenia Risk in Anticoagulation

• Thrombocytopenia occurs in 1-13% of patients with acute coronary syndromes and is associated with a 2-8 times higher risk of thrombotic events, MI, major bleeding, and in-hospital mortality 1
• A platelet count nadir of 125 × 10^9/L has been identified as a threshold below which bleeding risk increases linearly 1
• Thrombocytopenia on presentation or related to antithrombotic therapy significantly increases risk of adverse outcomes 1

Apixaban Use in Thrombocytopenia

Risk Assessment and Decision-Making

• Unlike GP IIb/IIIa inhibitors, which are generally contraindicated in thrombocytopenia, direct oral anticoagulants like apixaban may be considered in certain scenarios 1
• Recent evidence suggests apixaban may have a favorable safety profile in patients with thrombocytopenia compared to warfarin 2
• In a study of patients with VTE and risk factors for bleeding (including thrombocytopenia), apixaban demonstrated lower risk of recurrent VTE (HR 0.72) and major bleeding (HR 0.70) compared to warfarin 2

Special Considerations for Heparin-Induced Thrombocytopenia (HIT)

• For heparin-induced thrombocytopenia, emerging evidence supports apixaban as a potential alternative anticoagulant 1, 3
• In a pilot study of 30 patients with suspected HIT treated with apixaban, platelet counts normalized in all patients with no new thrombosis and only one hemorrhagic event 3
• Laboratory studies have confirmed that apixaban does not interact with HIT antibodies, showing no significant platelet activation in the presence of HIT antibodies 4

Monitoring and Management Recommendations

• For patients requiring anticoagulation who have thrombocytopenia:

  • Assess bleeding risk based on platelet count, with increased caution below 125 × 10^9/L 1
  • Consider alternative anticoagulants (direct thrombin inhibitors) in severe thrombocytopenia, especially with platelet counts <50 × 10^9/L 1
  • Monitor platelet counts regularly during treatment 1

• For patients with mild to moderate thrombocytopenia (>50 × 10^9/L) requiring anticoagulation:

  • Apixaban may be considered with close monitoring 3, 2
  • Standard dosing can be used in the absence of other contraindications 5, 6

Important Caveats

• Apixaban should be avoided in patients with severe renal impairment (CrCl <15 mL/min) or hepatic impairment 1
• The combination of thrombocytopenia with other bleeding risk factors (renal impairment, advanced age, low body weight) may warrant dose adjustment or alternative anticoagulation 1
• Most clinical trials of apixaban excluded patients with severe thrombocytopenia, so evidence in this population is limited 1

Conclusion

While not absolutely contraindicated, apixaban should be used with caution in thrombocytopenia, especially when platelet counts fall below 125 × 10^9/L. The decision to use apixaban should balance thrombotic and bleeding risks, with consideration of alternative anticoagulants in severe thrombocytopenia.